WHO Collaborating Centre for Patient Safety Solutions

Aide Memoire

Avoiding Catheter and Tubing Mis-Connections

Patient Safety Solutions

| volume 1, solution 7 | May 2007

Statement of Problem and Impact:

Tubing, catheters, and syringes are a fundamental aspect of
daily health care provision for the delivery of medications and
fluids to patients. The design of these devices is such that it is
possible to inadvertently connect the wrong syringes and tubing
and then deliver medication or fluids through an unintended
and therefore wrong route. This is due to the multiple devices
used for different routes of administration being able to connect
to each other. The best solution lies with introducing design features that prevent misconnections and prompt the user to take
the correct action.
Other causes or contributing factors include:
Luer connectors. Used almost universally in a variety of
medical applications to link medical devices, including
fluid delivery (via the enteral, intravascular, spinal, and
epidural routes) and insufflation of gas (in balloon catheters, endotracheal cuffs, and automatic blood pressure
devices), they have been found to enable functionally
dissimilar tubes or catheters to be connected.
Routine use of tubes or catheters for unintended purposes. This includes using intravenous (IV) extension
tubing for epidurals, irrigation, drains, and central lines
or to extend enteric feeding tubes.
Positioning of functionally dissimilar tubes used in patient care in close proximity to one another. For example, use of an enteral feeding tube near a central intravenous catheter and tubing.
Movement of the patient from one setting or service
to another.
Staff fatigue associated with working consecutive shifts.
Tubing and catheter misconnections can lead to wrong route
medication errors and result in serious injury or death to the pa-

tient. Though these errors are highly preventable and can often
be easily averted, multiple reports of patient injury and death
from such wrong route medication errors indicate that they occur with relative frequency (1-7). This includes erroneous administration routes for aerosols.
In the United States of America (USA), nine cases of tubing
misconnections involving seven adults and two infants have
been reported to the Joint Commissions Sentinel Event database, resulting in eight deaths and one permanent loss of function (8). Similar incidents have been reported to other agencies, including the ECRI Institute, the United States Food and
Drug Administration, the Institute for Safe Medication Practices
(ISMP), and the United States Pharmacopeia (USP). Data from
these groups reveal that misconnection errors occur with significant frequency and, in a number of instances, lead to deadly
consequences (9,10).
The most common types of tubes and catheters involved in the
cases reported to the Joint Commission are central venous catheters, peripheral IV catheters, nasogastric feeding tubes, percutaneous enteric feeding tubes, peritoneal dialysis catheters,
tracheostomy cuff inflation tubes, and automatic blood pressure cuff insufflator tubes. Examples include specific misconnections involving an enteric tube feeding into an IV catheter
(four cases); a blood pressure insufflator tube connected to an
IV catheter (two cases); and the injection of intravenous fluid
into a tracheostomy cuff inflation tube (one case).
In the United Kingdom, between 2001 and 2004, there were
three reports of death, and from 1997 to 2004 there were four reports of harm or near misses following wrong route errors when
oral liquid medicines, feeds, and flushes were administered intravenously (11). A review of the National Reporting
and Learning System in the United Kingdom identi-

fied 32 reported incidents in which oral liquid medicines

were administered by the intravenous route, seven incidents
in which epidural medication was administered via the
intravenous route, and six incidents in which intravenous
medication was administered via the epidural route from
1 January 2005 to 31 May 2006.

Associated Issues:
While various approaches to preventing catheter misconnection and wrong route administration have been suggested, meticulous attention to detail when administering
medications and feedings (i.e. the right route of administration) and when connecting devices to patients (i.e. using
the right connection/tubing) is a basic first step. By implementing preventive measuresmany of them simple and
inexpensivewrong route administration errors can be
effectively eliminated.

Suggested Actions:
The following strategies should be considered by WHO
Member States.
1. Ensure that health-care organizations have systems
and procedures in place which:
Emphasize to non-clinical staff, patients, and families that devices should never be connected or
disconnected by them. Help should always be requested from clinical staff.
Require the labeling of high-risk catheters (e.g.
arterial, epidural, intrathecal). Use of catheters
with injection ports for these applications is to
be avoided.
Require that caregivers trace all lines from their
origin to the connection port to verify attachments
before making any connections or reconnections, or administering medications, solutions, or
other products.
Include a standardized line reconciliation process
as part of handover communications. This should
involve rechecking tubing connections and tracing all patient tubes and catheters to their sources
upon the patients arrival in a new setting or service
and at staff shift changes.
Bar the use of standard Luer-connection syringes to
administer oral medications or enteric feedings.
Provide for acceptance testing and risk assessment
(failure mode and effects analysis, etc.) to identify
the potential for misconnections when purchasing
new catheters and tubing.

2. Incorporate training on the hazards of misconnecting

tubing and devices into the orientation and continuing
professional development of practitioners and healthcare workers.
3. Promote the purchasing of tubes and catheters that are
designed to enhance safety and to prevent misconnections with other devices or tubes.

Looking Forward:
1. Physical barriers (e.g. incompatibility by design)
should be created to eliminate the possibility of interconnectivity between functionally dissimilar medical
tubes and catheters to the extent feasible.
2. Specific labeling of device ports is advocated to avoid
connecting intravenous tubing to catheter cuffs or
balloons (3).
3. The use of different, dedicated infusion pumps for specific applications such as epidural infusions has also
been proposed (12).
4. Using only oral/enteral syringes to administer oral/enteral medications and avoiding the use of adapters and
three-way taps are part of several draft proposals from
the United Kingdoms National Patient Safety Agency
to prevent wrong route errors (13).
5. A combined preventive strategy of performing risk assessments to identify existing misconnection hazards,
encouraging manufacturers to design dissimilar catheters and tubes to be physically impossible to connect
(incompatibility by design), acquisition of equipment whose design makes misconnections unlikely,
and policy implementation to minimize misconnection occurrences has been advocated (14,15).
6. The colour-coding of tubing and connections should
be standardized. The European standardization body
has studied the colour-coding of tubing and connectors in certain applications and has recommended
exploring alternatives to Luer connectors in selected
applications (16).
7. Industry-based standards and engineering design for
medical tubes and catheters that are organ-specific or
need-specific and do not interconnect should be established and promoted.

Strength of Evidence:
Expert consensus.

 Applicability:
Wherever patients are treated, including hospitals, mental health facilities, community settings, ambulatory clinics, long-term care facilities, clinics, practices, homecare agencies.

Opportunities for Patient and

Family Involvement:
Encourage patients and families to ask questions about
medications given parenterally or via feeding tubes, to
assure proper medication delivery.
Educate patients, families, and caregivers on the proper
use of parenteral sites and feeding tubes in the home care
setting and provide instruction on the precautions to take
to prevent wrong route errors.

4.

5.
6.

7.

8.

9.

10.
11.

Potential Barriers:
Staff acceptance of the concept of wrong route error
prevention.

12.

Staff acceptance of never modifying incompatible connectors to allow connections.

13.

Cost of converting to non-connectable delivery systems.

Inability to create an approach or standardization
of systems.
Difficulties with a consistent or reliable supply chain for
some countries.
Insufficient generally accepted research, data, and
economic rationale regarding cost-benefit analysis or return on investment (ROI) for implementing
these recommendations.

Risks for Unintended

Consequences:
Possible treatment delays to obtain compatible equipment if compatible connections are not available.

Selected References and

Resources:
1.

2.

3.

Tunneled intrathecal catheter mistaken as central venous line access. ISMP Canada Safety Bulletin, 30 October 2005. http://www.
ismp-canada.org/download/ISMPCSB2005-08Intrathecal.pdf.
Problems persist with life-threatening tubing misconnections. ISMP
Medication Safety Alert, 17 June 2004. http://www.ismp.org/
newsletters/acutecare/articles/20040617.asp?ptr=y.
Wichman K, Hyland S. Medication safety alerts. Inflation ports:
risk for medication errors. Canadian Journal of Hospital Pharmacy,
2004, 57(5):299301. http://www.ismp-canada.org/download/
cjhp0411.pdf.

14.
15.
16.

Ramsay SJ et al. The dangers of trying to make ends meet: accidental intravenous administration of enteral feed. Anaesthesia and
Intensive Care, 2003, 31:324327.
Pope M. A mix-up of tubes. American Journal of Nursing, 2002;
102(4):23.
Wrong route errors. Safety First, Massachusetts Coalition for the
Prevention of Healthcare Errors, June 1999 (http://www.macoalition.org/documents/SafetyFirst1.pdf, accessed 10 June 2006).
Tubing
misconnectionsa
persistent
and
potentially deadly occurrence. Sentinel Event Alert, April
2006.
Joint
Commission.
http://www.jointcommission.
org/SentinelEvents/SentinelEventAlert/sea_36.htm.
Vecchione A. JCAHO warns of tubing errors. Health-System Edition,
22 May 2006 (http://mediwire.healingwell.com/main/Default.asp
x?P=Content&ArticleID=326253, accessed 10 June 2006).
Cousins DH, Upton DR. Medication errors: oral paracetamol liquid administered intravenously: time for hospitals to issue oral syringes to clinical areas? Pharmacy in Practice, 2001, 7:221.
Cousins DH, Upton DR. Medication errors: increased funding can
cut risks. Pharmacy in Practice, 1997, 7:597598
Building a safer NHS for patients: improving medication safety.
London, Department of Health, 2004 (http://www.dh.gov.uk/en/
Publicationsandstatistics/ Publications/PublicationsPolicyAndGuid
ance/DH_4071443 accessed 10 June 2006).
Koczmara C. Reports of epidural infusion errors. CACCN Dynamics,
2004, 15(4):8. http://www.ismp-canada.org/download/CACCNWinter04.pdf.
Preventing wrong route errors with oral/enteral medications, feeds
and flushes. National Patient Safety Agency Patient Safety Alert,
Draft responses to 1st consult, JanuaryMarch 2006. http://www.
saferhealthcare.org.uk/NR/rdonlyres/3F9F3FB2-89B6-4633ACE9-A51EC2023EBC/0/NPSAdraftpatientsafetyalertonoralconne
ctorsforstakeholderconsultation.pdf.
Preventing misconnections of lines and cables. Health Devices,
2006, 35(3):8195.
Common connectors pose a threat to safe practice, Texas Board of
Nursing Bulletin, April 2006.
Moore R. Making the right connections. Medical Device
Technology, 2003, 14(2):2627.

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